Project Summary/Abstract Project Background: Patients who transition from acute care to primary outpatient care are at high risk for adverse outcomes such as readmissions and medication errors. Primary care patients at the VA who utilize non-VA acute care services are at particularly high risk for these adverse outcomes because of lack of coordination between non-VA and VA sites. The Bronx RHIO, a newly established electronic health information network system, provides an opportunity to improve care coordination between non-VA and VA sites by providing a platform for sharing clinical data among facilities. We designed a care transition intervention based on the use of RHIO to provide patient-centered care targeted at improving communication, coordination of care and provider decision making using clinical data from RHIO. Project Objectives: 1) To determine the feasibility of a care transition intervention, enhanced by the use of RHIO, designed to improve outcomes of veterans discharged from a non-VA hospital or emergency department. 2) To demonstrate the implementation fidelity (recruitment, acceptance and adherence to the protocol) of the care transition intervention. 3) To identify the potential of the care transition intervention to improve the care of veterans, relative to: (a) primary outcomes of the rates of readmission to the hospital or emergency department (ED); and (b) secondary outcomes of the rates of medication duplication and error, and patient satisfaction. 4) To estimate the effect size of the care transition intervention compared to usual care for primary and secondary outcomes. Project Methods: The pilot intervention is designed to improve care transition of veterans recently discharged from non-VA hospitals or ED. The care transition intervention proposed is nurse-led and will contain components of care transition interventions which have been demonstrated to be effective in non-VA settings. The intervention will contain a structured protocol of nurse monitoring and retrieval of non-VA hospital and emergency department discharge information using the Bronx RHIO, coordination of urgent and follow-up appointments, condition specific patient education and communication, medication reconciliation, and provider communication. The intervention will be implemented among 30 James J Peters VA patients and outcome measures will be compared to 30 controls. The rates of readmission to hospitals or ED, the rates of medication duplication and error, and patient satisfaction will be collected as outcome measures. In addition, process data including participation rates, length of time necessary to recruit patients, and recruitment barriers will be collected.